Supermarket Risk Assessment Checklist Form
Complete this checklist to assess safety and operational risks in your supermarket areas. Use the ratings and checklists to identify hazards and document actions.
Store Name or ID
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessed Area
*
Please Select
Sales Floor
Storage/Backroom
Refrigerated Section
Loading Dock
Restrooms
Parking Lot
Other
Hazard Checklist (Select all that apply)
*
Wet or slippery floors
Obstructed walkways
Damaged shelving or fixtures
Improperly stored goods
Electrical hazards
Blocked emergency exits
Other
Overall Condition Rating
*
1
2
3
4
5
Incident or Observation Notes
Corrective Actions Required
Priority Level
*
Low
Medium
High
Responsible Person
*
First Name
Last Name
Follow-up Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Assessment
Should be Empty: